U.C. 


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HUNGER  IN  THE  INFANT 


Thesis    Submitted    to    the   Faculty   of   the    Graduate   School 
of  the  University  of  Minnesota 


BY 
ROOD  TAYLOR,   M.D. 


In  Partial   Fulfillment  of  the  Requirements   for  the   Degree  of  Doctor  of  Science 

1917 


HUNGER     IN     THE     INFANT* 

ROOD    TAYLOR,    M.D.,    Sc.D. 
Mayo  Clinic 

ROCHESTER,     MINN. 

Cannon  and  Washburn,1  and  Carlson  and  his  colaborers  have  given 
us  a  proved  method  for  studying  hunger  objectively;  its  time  of  occur- 
rence, its  intensity,  its  effects,  and  the  means  by  which  it  may  be  pro- 
duced or  inhibited.  They  have  shown  that  contractions  of  the  so-called 
empty  stomach  cause  the  hunger  sensation.  These  contractions  depend 
in  part  on  vagus  tonus.  They  can  be  increased  by  chemical  changes 
in  the  blood,  but  are  primarily  due  to  a  gastric  mechanism  as  purely 
automatic  as  is  that  of  the  heart. 

Impulses  set  up  by  these  contractions  and  carried  to  the  higher 
centers  are,  in  the  normal  consciousness,  recognized  as  hunger.  These 
impulses  produce  secondary  effects  such  as  restlessness  and  irritability. 
They  increase  the  reflex  excitability  of  the  central  nervous  system,  the 
heart  beats  faster,  and  there  are  changes  in  the  vasomotor  mechanism. 
Well  fed,  sedentary  adults  seldom  experience  hunger.  The  prime  fac- 
tor in  their  desire  for  food  depends  not  on  the  basis  of  distress  due  to 
the  contractions  of  a  hollow  viscus,  but  on  "the  memory  processes  of 
past  experience  with  palatable  foods."  This  psychic  factor  is  appetite, 
and  its  absolute  distinction  from  the  physical  factor,  hunger,  must  be 
kept  in  mind. 

Working  on  dogs,  Patterson,  in  1914,  showed  the  gastric  hunger 
contractions  to  be  much  more  frequent  and  vigorous  in  young  than  in 
older  animals.  In  1915,  Carlson  and  Ginsburg  described  the  great 
intensity  of  hunger  contractions  in  the  human  new-born.  Previous  to 
that  year  no  productive  analytic  studies  of  the  hunger  sense  in  the 
human  infant  had  been  made.  Appetite  and  hunger  were  not  dis- 
tinguished, and  the  sucking  mechanism  alone  had  been  analyzed. 

In  1888,  Auerbach  distinguished  the  infantile  type  of  sucking  from 
the  voluntary  inspiratory  type  employed  by  the  adult,  and  in  1894 
Basch,  disproving  the  older  theory  of  Preyer  that  sucking  is  instinctive, 
showed  it  to  be  entirely  reflex. 


*  From  the  Department  of  Pediatrics,  University  of  Minnesota. 

1.  All  references  to  the  literature  will  be  found  at  the  end  of  the  article. 


377 


Czerny,  in  1893,  observed  that  an  infant  awakened  a  short  time 
after  taking  his  fill  from  the  maternal  breast,  would  again  suck  vigor- 
ously if  placed  on  it,  and  concluded  that  sucking  per  se  could  not  be 
considered  as  a  sign  of  hunger.  A  few  years  later  (1900)  Keller  wrote 
that,  since  the  normal  infant  sleeps  three  hours  after  nursing,  although 
its  stomach  is  empty  in  two  hours,  the  emptying  of  the  stomach  cannot 
be  considered  a  positive  criterion  of  need  for  food.  Pies,  in  1910,  con- 
sidered the  reddening  and  eczema  of  the  lower  lip  which  occurs  in 
undernourished  infants  as  a  sign  of  hunger,  and  referred  it  directly  to 
the  infant's  fruitless  sucking.  In  1913  Schlossmann  concluded  from 
extensive  observations  on  semistarved  infants  that  the  sensation  of 
hunger  exists  only  in  the  imagination. 

Meyer  and  Rosenstern  studied  the  results  of  starvation  in  the  dif- 
ferent types  of  alimentary  disorder,  recording  particularly  the  pulse, 
temperature,  respiration  and  weight  changes.  Rosenstern  later  (1911- 
1912)  wrote  extensively  on  the  general  subjects  of  hunger  and  inani- 
tion in  infancy.  These  studies  are  all  defective  in  that  they  do  not 
distinguish  the  various  factors  concerned.  Neumann,  Pfaundler, 
Cramer,  Siiszwein,  Earth,  and  Kasahara  have  discussed  the  subject  of 
disturbances  in  the  food  urge  largely  from  the  point  of  view  of  imper- 
fections in  the  sucking  mechanism. 

The  present  studies  are  concerned  particularly  with  the  gastric  fac- 
tors in  the  urge  for  food.  The  major  of  these,  the  hunger  contrac- 
tions, was  studied  by  means  of  apparatus  similar  to  that  used  by 
Carlson.  A  rubber  balloon  of  about  20  c.c.  capacity  attached  to  one 
end  of  a  small  soft  rubber  catheter  is  inserted  into  the  stomach  and 
inflated,  the  catheter  is  attached  to  a  bromofonn  manometer  with  a 
cork  float  and  a  writing  pennant  which  records  the  gastric  movements 
on  smoked  paper. 

The  material  investigated  included  5  premature  infants  weighing 
from  1,200  to  2,500  gm.,  40  full  term  new-borns  under  3  weeks  of  age, 
and  11  older  babies,  5  between  1  and  2  months,  2  between  3  and  4 
months,  3  between  4  and  6  months,  and  1  boy  of  2  years  with  a  sur- 
gically induced  gastric  fistula  made  necessary  by  the  effects  of  corro- 
sive in  the  esophagus.  The  gastric  movements  of  some  of  the  infants 
were  recorded  only  once ;  on  others  as  many  as  twenty  observations 
were  made. 

Carlson  and  Ginsburg  refer  to  the  readiness  with  which  most 
infants  accept  and  retain  the  tube  and  balloon.  It  is  naturally  impos- 
sible to  secure  a  graphic  record  of  the  stomach  movements  of  a  raging 
infant.  Carlson  and  Ginsburg  did  their  work  on  full  term  new-borns. 
These  infants,  as  a  rule,  sleep  quietly  when  not  disturbed.  The  present 
work  was  carried  on  in  a  dimly  lighted,  quiet  room.  I  had  less  diffi- 
culty when  the  infant  was  left  undisturbed  in  his  crib  than  when  I 


attempted  innovations,  such  as  threading  a  pacifier  on  the  tube  or 
having  the  infant  held  in  the  nurse's  arms. 

The  older  babies  resent  the  presence  of  the  tube,  and  with  them  it 
\va>  often  necessary  to  make  repeated  attempts  to  secure  tracings. 
Some  infants  finally  became  accustomed  to  the  presence  of  the  tube 
and  slept  quietly,  particularly  if  the  experiments  were  conducted  in 
the  evening.  Most  of  the  tracings  on  the  2-year-old  boy  with  the 
gastric  fistula  were  made  when  he  was  awake.  The  greatest  problem 
was  to  keep  him  sufficiently  interested  to  prevent  crying  and  restless- 
ness and  at  the  same  time  to  prevent  riotous  hilarity.  In  his  case  the 
balloon  was  introduced  directly  through  the  fistula. 

It  is  said  that  passage  of  the  stomach  tube  in  infants  is  apt  to  cause 
aspiration  pneumonia.  Xo  ill  results  followed  the  procedure  carried 
out  in  these  studies. 

Does  the  presence  of  the  balloon  in  the  stomach  act  mechanically 
to  produce  gastric  contractions  ?  Carlson  states  definitely  that  it  does 
not,  and  gives  the  following  reasons  for  his  belief : 

1.  The  presence  of  the  distended  balloon  in  the  stomach  between  the  con- 
traction periods  does  not  induce  these  contractions. 

2.  In  Mr.  V.  [his  gastric  fistula  case]  the  gastric  contractions  can  be  observed 
directly  through  the  large  fistula  without  any  balloon  in  the  stomach. 

3.  The  contraction  periods  come  on  just  as  frequently  without  any  balloon  in 
the  stomach  and  produce  the  same  effect  (hunger). 

4.  In  pigeons  the  periodic  strong  contractions  of  the  empty  crop  can  be  seen 
directly  through  the  skin,  and  a  balloon  in  the  crop  does  not  alter  their  frequency 
or  intensity. 

The  results  of  this  work  fully  confirm  Carlson  and  Ginsburg's 
report  that  the  stomach  of  the  new-born  infant  exhibits  greater  hunger 
contraction  than  does  that  of  the  adult.  The  intervals  between  the 
contraction  periods  are  often  less  than  five  minutes  and  usually  not 
longer  than  from  ten  to  twenty  minutes.  The  first  contraction  period 
after  a  nursing  is  apt  to  consist  of  from  five  to  twenty  separate  con- 
tractions and  to  last  from  two  to  eight  minutes.  The  succeeding  con- 
traction periods  frequently  endure  from  thirty  minutes  to  an  hour  or 
even  longer.  The  duration  of  each  contraction  is  about  twenty  seconds. 
In  many  of  the  infants  the  contraction  time  of  the  more  powerful  con- 
tractions, especially  in  those  periods  ending  in  partial  tetanus,  was 
about  eighteen  seconds.  Except  in  the  first  contraction  period  after  a 
nursing,  endings  in  partial  tetanus  were  frequently  observed.  Partial 
tetanus  is  sometimes  present  before  the  close  of  the  period.  With  the 
apparatus  used,  the  force  of  the  single  contractions  usually  sufficed  to 
raise  the  column  of  bromoform  2  to  3  cm.  During  partial  tetanus  the 
bromoform  may  be  raised  5  cm. 

Patterson  found  practically  continuous  hunger  contractions  in  pre- 
mature pups.  It  is  particularly  easy  to  obtain  graphic  records  of  the 


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hunger  contractions  of  the  somnolent,  prematurely  born  infant.  The 
stomach  of  such  an  infant  is  in  a  state  of  nearly  continuous  contraction. 
The  individual  contractions  require  about  the  same  length  of  time  for 
their  completion  and  are  as  powerful  as  those  of  the  full  term  infant. 
In  a  tracing  begun  forty  minutes  after  a  feeding  of  15  gm.  of  breast 
milk  to  a  premature  baby  (Baby  5)  weighing  1,510  gm.,  the  record 
appears  very  like  that  obtained  by  Rogers  from  the  crop  of  a  pigeon 
in  the  second  day  of  starvation.  The  periods  of  contraction  last  two 
or  three  minutes,  with  intervening  periods  of  quiescence  of  about  the 
same  length.  The  individual  contractions  last  twelve  to  fifteen  seconds 
and  raise  the  bromoform  column  3  to  4  cm.  Partial  tetanus  is  fre- 
quent. Xine  days  later,  when  the  infant  was  receiving  more  food,  in 
spite  of  the  fact  that  he  had  not  gained  in  weight  and  that  the  tracing 
was  begun  five  hours  after  his  last  feeding,  the  record  obtained  was 
similar  to  those  from  other  infants. 

Are  the  hunger  contractions  more  frequent  or  more  powerful  in 
cyanosed  infants?  May  they  furnish  a  stimulus  for  crying  with  con- 
sequent better  aeration  of  the  lungs?  In  two  such  cases  no  significant 
increase  or  decrease  in  the  hunger  contractions  could  be  observed.  No 
records  were  taken  from  any  cyanosed  premature  infants,  although 
such  infants  are  frequently  slightly  blue  for  the  first  few  days. 

Carlson,  working  on  the  adult,  was  unable  to  produce  hunger  con- 
tractions by  any  sort  of  stimulus  acting  directly  in  the  mouth  or  in  the 
stomach,  except  that  he  occasionally  could,  by  suddenly  distending  the 
stomach,  produce  a  few  transitory  contractions.  He  found,  uniformly, 
that  the  only  effect  of  such  local  stimulation  was  inhibitory.  In  gen- 
eral, the  taste  of  salt,  sour,  bitter,  or  sweet ;  or  the  chewing  of  agree- 
able, disagreeable,  or  indifferent  substances,  all  produce  temporary 
inhibition  of  the  gastric  contractions.  Chewing  palatable  foods  by  the 
adult  when  hungry  causes  an  inhibition,  made  more  lasting  by  the  flow 
of  appetite  juice  in  the  stomach. 

Carlson  found  that  acid  and  alkaline  solutions,  food  and  liquids 
in  the  stomach,  all  inhibit  the  hunger  contractions.  Inhibition  from 
the  stomach  is  less  transitory  than  that  from  the  mouth.  Boldyreff 
showed  that  the  periodic  contractions  of  the  empty  stomach  were 
inhibited  by  the  presence  of  acid  in  the  intestine.  Brunemeier  and 
Carlson  completed  and  enlarged  this  work.  They  demonstrated  inhibi- 
tion from  the  presence  of  gastric  juice  or  acid  chyme  in  the  small 
intestine.  This  inhibition  from  the  stomach  and  intestine  is  reflex, 
partly  through  Auerbach's  plexus,  but  mainly  through  the  long  reflex 
arc  with  the  efferent  path  to  the  stomach  muscles  through  the 
splanchnics. 

Inhibition  from  the  mouth  is  not  present  in  the  frog  (Patterson). 
Carlson,  who  suspects  that  such  inhibition  involves  conscious  cerebral 
processes,  has  suggested  experiments  in  infants  to  settle  the  point. 


Repeated  trials  with  breast  milk,  sugar  water,  common  salt,  quinin, 
and  lemon  juice  in  the  mouths  of  premature  and  new-born  infants  in 
my  study  failed  to  produce  inhibition  of  hunger  contractions. 

In  general  I  obtained  the  same  results  in  an  infant  of  8  weeks.  A 
transitory  inhibition  occurred  occasionally  when  sugar  water  was 
placed  in  his  mouth.  In  none  of  the  infants  did  chewing  or  sucking 
on  the  thumb  or  tube  produce  inhibition.  Nor  did  such  movements 
or  the  presence  of  sugar,  breast  milk  or  other  substances  in  the  mouth 
induce  hunger  contractions. 

The  boy  of  2  years  showed  inhibition  when  sugar  or  protein  milk 
(his  diet  at  the  time)  was  placed  in  his  mouth.  Quinin,  dilute  hydro- 
chloric acid,  small  amounts  of  sugar  water,  table  salt  in  crystals  or 
solution,  did  not  inhibit.  Benzosulphinidum  solution  inhibited  twice. 
It  was  not  used  subsequently.  The  sight  of  sugar  did  not  inhibit.  He 
began  to  cry  when  he  saw  his  bottle  if  the  latter  were  not  given  him 
immediately.  Conseqeuntly  the  effect  of  his  seeing  the  bottle  on  the 
hunger  contractions  could  not  be  registered.  During  the  periods  of 
quiescence  the  sight  of  the  nurse  who  fed  him  did  not  induce  hunger 
contractions,  although  he  began  to  whine  and  tease  when  she  entered 
the  room. 

Apparently  inhibition  from  the  mouth  was  produced  by  those  sub- 
stances only  which  the  child  regarded  as  food.  Quinin  very  evidently 
made  a  profound  sensory  impression,  but  did  not  inhibit  the  contrac- 
tions. Dilute  hydrochloric  acid  did  not  inhibit,  while  unsweetened 
protein  milk  (which  is  slightly  sour)  did. 

Carlson's  hypothesis  as  to  the  need  of  conscious  cerebration  for  the 
production  of  inhibitory  reflexes  from  the  mouth  would  appear  to  offer 
the  correct  explanation.  It  seems  to  be  agreed  that  the  new-born 
infant  leads  a  subcortical  reflex  existence  (Soltmann-Cramer).  Kuss- 
maul  and  Thiemich  note  that  the  new-born  infant  accepts  sugar  and 
rejects  salt,  food  that  is  sour  and  bitter  —  action  which  is  almost  cer- 
tainly purely  reflex  on  the  part  of  the  infant. 

My  work  shows  that  when  20  c.c.  of  water  or  milk  are  introduced 
into  the  stomach  during  a  contraction  period  inhibition  follows  invari- 
ably. This  was  found  true  in  infants  of  all  ages.  With  small  amounts 
of  water  the  inhibition  often  lasted  only  three  or  four  minutes,  when 
the  contraction  period  would  be  resumed. 

On  the  other  hand,  it  was  not  unusual  to  recover  from  15  to  40  cm. 
of  clotted  milk  through  the  stomach  tube  even  an  hour  after  vigorous 
hunger  contractions  had  begun.  This  is  a  considerable  portion  of  the 
infant's  meal,  and  in  these  cases  would  represent  from  one-sixth  to 
one-fourth  of  his  total  intake  at  the  previous  feeding.  Soltmann 
showed  that  the  inhibiting  nervous  mechanism  of  the  heart  is  much  less 
effectual  in  the  new-born  infant  than  in  later  life.  It  seems  possible 


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that  the  nervous  apparatus  for  the  inhibition  of  the  gastric  hunger 
movements  may  likewise  be  immature.  Or  the  tissue  hunger  may  be 
so  great  as  to  overcome  any  but  the  strong  inhibition  of  a  heavily  laden 
stomach  and  duodenum. 

The  vagi  form  the  sensory  pathway  from  the  stomach  to  the  brain. 
The  first  reflex  centers  are  the  sensory  nuclei  of  the  vagi  in  the  medulla. 
A  second  center,  possibly  that  for  conscious  hunger,  is  located  in  the 
optic  thalami.  Rogers  has  shown  that  the  picking  reflex  in  the  pigeon 
(analogous  to  the  sucking  reflex  in  the  babe)  is  abolished  on  removal 
of  the  thalami. 

The  reflex  irritability  (as  indicated  by  the  knee  jerk)  is  increased 
synchronously  with  each  hunger  contraction  (Carlson).  No  observa- 
tions have  been  made  on  the  infant's  knee  jerks  during  the  hunger 
state ;  but  Zybell  has  shown  that  the  electrical  irritability  increases 
during  the  first  eighteen  hours  of  starvation. 

Let  us  summarize  the  events  from  the  close  of  one  meal  till  the 
end  of  the  next.  The  infant  sleeps.  The  upper  stomach  musculature 
maintains  a  tonic  grasp  on  the  contained  food.  The  pyloric  antrum 
is  traversed  by  peristaltic  waves  (Cannon).  The  stomach  gradually 
empties.  The  point  of  origin  of  the  peristaltic  waves  rises  higher  and 
higher.  The  tonus  rhythm  of  the  fundus  begins.  The  stomach  empties 
itself  more  completely,  the  tonus  rhythm  becomes  more  intense,  and 
the  first  hunger  contractions  appear  (Rogers  and  Hardt). 

The  first  contraction  period  is  apt  to  be  short.  After  a  wait  of 
perhaps  twenty  minutes  a  longer  and  more  intense  hunger  period 
arrives ;  then  another  and  another.  The  infant's  sleep  becomes  lighter. 
He  is  more  easily  awakened  by  external  stimuli  or  by  gastric  discom- 
fort. He  is  put  to  the  breast,  nurses  vigorously,  becomes  fatigued 
(Schmidt,  Cramer,  Pfaundler),  or  experiences  satiety  from  distention 
(Neisser  and  Brauning)  and  again  goes  to  sleep. 

What  constitutes  the  hunger  state?  Does  it  result  from  the  sum- 
mation of  impulses  with  an  increasing  psychic  and  reflex  irritability? 
The  evidence  is  to  the  contrary.  The  increase  in  the  reflex  excitability 
is  synchronous  with  the  contraction  phase  of  the  stomach,  and  is  absent 
in  the  intervals  between  the  contractions.  In  the  infant  who  has  been 
some  hours  without  food  the  hunger  contractions  are  nearly  continu- 
ous, and  it  would  be  expected  that  the  reflex  excitability  would  be 
nearly  continuously  high. 

In  the  absence  of  hunger  contractions  the  infant  often  sucks  vigor- 
ously on  the  tube  attached  to  the  balloon.  The  receptive  mechanism  for 
the  institution  of  the  sucking  reflex  is  so  delicate  that  it  is  impossible 
to  provide,  artificially,  a  minimal  stimulus.  During  the  hunger  state, 
when  presumably  a  rapid  succession  of  hunger  contractions  maintains 
a  low  reflex  threshold,  there  may  often  be  observed  a  succession  of 


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automatic  sucking  movements  involving  the  lips,  tongue  and  lower  jaw, 
each  movement  providing  the  necessary  stimulus  for  its  successor. 

The  lay  mind  is  prone  to  think  that  the  crying  infant  is  hungry. 
Comby  and  Czerny  and  Keller  believe  that  hunger  is  a  minor  cause  of 
crying.  Rosenstern  notes  that  in  hunger  young  babies  are  usually 
quiet,  but  that  the  older  infants  cry  more.  Schlossmann  remarks  that 
the  normal  infant  endures  hunger  well. 

Observations  on  this  point  extending  over  sixteen  months  of  study 
of  the  hunger  sensation  lead  me  to  believe  that  in  normally  thriving 
breast  fed  infants,  except  when  more  than  three  or  lour  hours  have 
elapsed  since  the  last  feeding,  neither  the  hunger  contractions  them- 
selves nor  the  increased  irritability  due  to  them  are  ordinarily  immedi- 
ate factors  in  the  production  of  crying.  Young  infants  sleep  through- 
out strong  contraction  periods.  Older  infants  often  do  the  same,  and 
are  frequently  quiet  even  from  twelve  to  sixteen  hours  after  a  feeding. 
Mental  factors  produce  crying  at  a  very  early  age.  And  the  fact  that 
crying  ceases  when  food  or  water  is  administered  may  only  mean  that 
the  infant's  attention  is  diverted  to  the  performance  of  a  pleasur- 
able act. 

It  may  be  noted  in  this  connection  that  the  2-year-old  boy  was 
happier  when  allowed  to  take  food  into  his  mouth,  and  that  his  outlook 
on  life  was  much  more  cheerful  on  days  when  he  could  take  nourish- 
ment by  mouth  than  on  other  days  when  the  esophageal  constriction 
increased,  and  it  became  necessary  to  introduce  the  food  through  the 
gastric  fistula.  This  feeding  through  the  fistula  was  without  pain,  and 
the  child  submitted  to  it  with  some  pleasure. 

What  is  the  time  interval  between  feeding  and  the  first  appearance 
of  gastric  hunger  contractions?  Ginsburg,  Tumpowsky  and  Carlson 
studied  this  point  in  thirty  normal  breast  fed  infants  under  4  weeks  of 
age.  They  gave  no  data  as  to  gain  in  weight  and  did  not  determine 
the  amount  of  food  taken,  but  stated  that  the  babes  nursed  till  satisfied. 
They  found  the  average  time  between  nursing  and  the  appearance  of 
hunger  contractions  to  be  two  hours  and  forty  minutes,  with  a  mini- 
mum of  two  hours  and  twenty  minutes  and  a  maximum  of  three  hours 
and  thirty  minutes.  My  observations  on  twelve  new-born  infants 
under  like  conditions  yielded  these  results ;  a  minimum  of  one  hour  and 
thirty  minutes,  a  maximum  of  three  hours  and  thirty  minutes,  and  an 
average  of  about  two  and  one-half  hours. 

Many  infants  in  the  first  two  weeks  do  not  receive  a  sufficient  supply 
of  breast  milk.  This  is  particularly  apt  to  be  true  of  the  time  the  babe 
and  the  mother  remain  in  the  hospital.  Consequently,  observations 
made  under  the  conditions  so  far  outlined  may  be  misleading.  Table  1 
(A,  B  and  C)  gives  the  results  of  all  satisfactory  tracings  obtained 
from  normally  thriving  babies  on  whom  sufficient  data  as  to  food 
intake  and  weight  gain  were  obtained. 


TABLE   1. — INTERVAL  FOR   DEVELOPMENT   OF   HUNGER 

A.     PREMATURE    INFANTS 


Name 

Age, 
Days 

Food 

Feeding 
Interval 

Quan- 
tity at 
Feeding 

Interval           Time  for 
Before          Development 
Tracing        of  First  Hun- 
ger Period 

Remarks 

Sw. 

7 

Breast  milk 

4  hours 

35  c.c. 

None                40  min. 

Premature  Wt.  2,140  gm. 

5  times  a  day 

Sw. 

11 

Breast  milk 

4  hours 

SOc.c. 

20min.         lhr.,20min. 

Wt.  2,240  gm. 

5  times  a  day 

Sw. 

20 

Breast  milk 

4  hours 

90  c.c. 

52  min.               2  hours 

Wt.  2,470  gm. 

5  times  a  day 

Sw. 

25 

Breast  milk 

4  hours 

75  gm. 

38min.          1  hr.,  50  min. 

Wt.  2,565  gm. 

5  times  a  day 

St. 

13 

Breast  milk 

4  hours 

30  c.c. 

None               1  hour 

Premature  "Wt.  2,270  gm. 

5  times  a  day 

St. 

14 

Breast  milk 

4  hours 

SOc.c. 

None                40  min. 

Wt.  2,280  gm. 

5  times  a  day 

St. 

25 

Breast  milk 

4  hours 

SOc.c. 

1  hr.,  13  min.     1  hr.,  15  min. 

Wt.  2,450  gm. 

5  times  a  day 

St. 

28 

Breast  milk 

4  hours 

90  c.c. 

38  min.              1  hour 

Wt. 

5  times  a  day 

St. 

36 

Breast  milk 

4  hours 

100  c.c. 

32  min.          lhr.,50min. 

Wt.  2,720  gm. 

5  times  a  day 

Fre. 

9 

Breast  milk 

4  hours 

45  C.C. 

Ihr.,  38  min.     1  hr.,  38  min.     Premature  Wt.  1,380  gm. 

6  times  a  day 

Fre. 

15 

Breast  milk 

4  hours 

45  C.C. 

1  hr.,  IS  min.     1  hr.,  18  min.                        Wt.  1,530  em. 

6  times  a  day 

Fre 

16 

Breast  milk 

4  hours 

45  C.C. 

23  min.         1  hr.,  15  min. 

Wt.  1,535  gm. 

6  times  a  day 

Fre 

21 

Breast  milk 

4  hours 

65  c.c. 

2  hours         2  hr.,  20  min. 

Wt.  1,710  gm. 

6  times  a  day 

B.    FULL    TERM    NEW-BORN    INFANTS 


H. 

8 

Breast  milk 

4  hours 

1 

1  hr.,  22  min. 

3  hr.,  50  min. 

Wt.  3,590  gm.;  gain  in  4 

5  times  a  day 

days,  90  gm. 

Day. 

8 

Breast  milk 

3  hours 

75  gm. 

1  hr.,  55  min. 

2  hr.,  25  min.     Wt.  4,l(iO  gm.;   gain  in  5 

8  times  a  day 

days  200  gm.;   10  c.c.  of 

milk  clot  removed  from 

stomach  1  hr.   after  be- 

ginning  of  hunger  con- 

tractions 

Day. 

9 

Breast  milk 

4  hours 

1 

2  hr.,  30  min. 

2  hr.,  30  min.  i  Wt.  4,200  gm.;  gain  In  6 

(for  preceding 

days,    300   gm.;    V4   c.c. 

24  hours) 

thick     mucus     removed 

5  times  a  day 

from    stomach     V4    hr. 

after  beginning  of  hun- 

ger contractions 

Wes. 

8 

Breast  milk 

4  hours        :  100  gm. 

1  hr.,  30  min. 

3  hr.,  10  min.     14  hours  fast  previous  to 

5  times  a  day 

last  feeding 

A. 

9 

Breast  milk  + 

3  hours 

70  gm. 

1  hr.,  45  min. 

2  hr.,  10  min.     Wt.  3,610  gm.;   gain  in  6 

cow's  milk)__ 

8  times  a  day 

days  230  gm.;  2o  c.c.  of 

8%  lactose) 

thick  soft  milk  clot  re- 

moved from  stomach  50 

min.  after  beginning  of 

hunger  contractions 

A. 

10 

Breast  milk  + 

70  em. 

1  hr.,  52  min. 

2  hours 

15  c.c.  of  fluid  and  curds 

cow's  milk? 

removed    from  stomach 

8%  lactoses88 

;    30  min.   after  beginning 

of  hunger  contractions 

Wai. 

10 

Breast  milk 

4  hours           95  gm. 

1  hr.,  30  min. 

4  hours 

Wt.  3,240  gm.;  gain  in  6 

5  times  a  day 

days,  260  gm. 

D. 

12 

Breast  milk 

4  hours 

115  gm. 

2  hr.,  30  min. 

2  hr.,  30  min. 

Wt.  3,720  gm.;  gain  in  7 

5  times  a  day 

days,  400  gm. 

C.    NORMAL   INFANTS    OVER    TWO   WEEKS    OF    AGE 

Gor. 

18 

Breast  milk 

4  hours 

85  gm. 

2  hr.,  23  min. 

4  hours        Wt.  3,500  gm.;  gain  in  13 

5  times  a  day 

days,  70  gm. 

Gor. 

19 

Breast  milk 

4  hours       :  110  gm. 

1  hr.,  58  min. 

3  hr.,  25  min. 

5  times  a  day 

Mos. 

Way. 

3.5 

Buttermilk  + 

4  hours 

150  c.c. 

2  hr.,  27  min. 

3  hr.,  12  min.     Wt.  4,960  gm.;  gain  in  7 

flour  +             5  times  a  day 

days,  440  gm. 

saccharose 

Way. 

3.5 

Buttermilk  +           4  hours           150  c.c. 

57  min. 

3  hr.,  20  min.     40    c.c.     of     thick     white 

flour  +             5  times  a  day 

materal    removed    from 

saccharose 

stomach    20   min.    after 

beginning     of     contrac- 

tion period 

Way. 

3.5 

Buttermilk  +           4  hours          150  c.c. 

2  hr.,  3  min. 

4  hr.,  35  min. 

flour  +             5  times  a  day 

saccharose 

Herm. 

4 

Breast  milk         2  or  3  hours 

1 

2  hr.,  45  min. 

3  hr..  30  min.     Well    nourished;    gaining 

irregular 

in  weight;  normal  baby; 

cared  for  at  home;  not 

in  hospital 

J. 

4 

Breast  milk 

5  times  a  day 

1 

2  hr.,  15  min. 

3  hr.,  30  min.     Well    nourished;    gaining 

in  weight;  normal  baby; 

cared  for  at  home;  not 

in  hospital 

Ad. 

4 

Malt  soup              4  hours           125  c.c. 

2  hr  ,  37  min. 

3  hr.,  30  min. 

Wt.  3,500  gm.;  gain  in  2 

5  times  a  day 

weeks,    200  gm.;   prema- 

turely born;  l.UOOgm.  at 

birth 

13 

The  time  required  for  the  development  of  hunger  in  the  premature 
infant  is  noticeably  short.  In  the  case  of  the  full  term  ne\v-borns  the 
figures  obtained  agree  fairly  well  with  those  given  by  Ginsburg,  Tum- 
powsky  and  Carlson,  but  are  definitely  greater  than  those  obtained  by 
me  (mentioned  in  a  preceding  paragraph)  from  infants  whose  food 
intake  was  net  accurately  known. 

The  time  required  for  the  development  of  hunger  in  any  one  infant- 
is  fairly  constant  over  a  short  period  of  time,  provided  the  amount  and 
kind  of  food  is  not  changed.  This  conclusion  rests  not  only  on  the 
results  shown  in  Table  1,  but  on  a  dozen  other  observations  on  infants 
whose  feeding  conditions  remained  constant  during  the  time  in  which 
studies  were  made. 

With  the  older  infants  difficulty  in  maintaining  quiet,  after  the 
insertion  of  tube  and  balloon,  limits  the  number  of  observations  which 
give  positive  evidence  as  to  the  first  appearance  of  hunger  contractions. 
Many  less  successful  observations  on  healthy,  normally  developing 
infants  yield  this  negative  evidence  that  in  such  infants  more  than  a 
month  old  I  did  not  observe  the  development  of  hunger  before  the  end 
of  three  hours. 

It  should  be  noted  further  that  the  contraction  period,  the  first 
appearance  of  which  is  recorded  in  Table  1,  is  the  first  one  to  develop 
after  feeding.  This  period  is  usually  short  and  is  not  made  up  of 
forceful  contractions.  With  Infants  J.  and  A.  more  intense  and  more 
nearly  continuous  contractions  did  not  begin  for  four  and  four  and  a 
half  hours,  respectively. 

Habits  as  to  feeding  interval  affect  the  time  required  for  the  devel- 
opment of  hunger  chiefly  as  they  influence  the  emptying  time  of  the 
stomach.  It  has  been  shown  that  the  speed  of  gastric  emptying  is  pro- 
portional to  the  length  of  time  during  which  the  individual  has  been 
without  food  (Tobler,  Haudek  and  Stigler),  and  that  large  feedings 
are  emptied  with  relatively  greater  rapidity  than  small  ones  (Tobler 
and  Bogen).  Habits  undoubtedly  exert  a  more  powerful  influence  or. 
the  mental  factors  associated  with  appetite  than  on  hunger  itself. 

Tables  2,  3  and  4  illustrate  the  shorter  time  required  for  the  devel- 
opment of  hunger  in  infants  with  chronic  nourishment  disturbance, 
and  indicate  that  the  presence  of  hunger  contractions  is  not  in  itself 
evidence  that  the  stomach  is  ready  for  food. 

In  the  columns  headed  "Remarks"  in  Tables  1,  2,  3  and  4,  there  are 
notes  as  to  material  recovered  with  the  stomach  tube  after  the  onset 
of  gastric  hunger  contractions.  In  normal  babies,  however,  there  prob- 
ably does  exist  a  relation  between  the  emptying  time  of  the  stomach 
and  the  interval  for  the  development  of  hunger. 

Observations  on  the  emptying  time  in  infants,  so  far  reported,  have 
been  made  either  with  the  relatively  stiff  catheter,  the  stomach  tube. 


15 


or  the  Roentgen  ray.  The  flexible  tube  introduced  by  Rehfuss  should 
replace  the  catheter  for  this  purpose ;  it  was  used  in  my  work.  The 
literature  contains  no  reports  of  the  time  required  for  gastric  digestion 
in  the  premature  infant.  The  emptying  time  in  normal  breast-fed 
infants  under  1  week  is  usually  less  than  one  hour  (Leo).  The 
Roentgen-ray  observations  of  Ladd  and  of  Tobler  and  Bogen  would 
indicate  that  in  normal  breast-fed  infants  the  stomach  is  frequently 
not  empty  until  after  two  to  three  hours.  The  figures  obtained  with 
the  use  of  the  stomach  tube  by  Epstein,  Czerny,  Keller  and  Cassel  indi- 
cate a  delayed  emptying  time  in  gastro-intestinal  disease. 

TABLE  2.— HUNGER   IN   ATROPHY    RESULTING   FROM    CONTINUED   STARVATION 

N.  N.,  aged  2  years;  gastric  fistula;  weight  fluctuating  between  6.SOO  gm.  and  7,200  gm.;   typhoid  fever 
Dec.  1  until  Dec.  14,  1916. 


Date 
1916 

Food 

Time  of     Beginning 
Last              of 
Feeding      Ttracing 

10/19 

Diluted  cow's  milk  + 

6a.m.     10:15  a.m. 

Practically  continuous  hunger  periods  until  10:50  a.  m. 

general  diet 

10/20 

Diluted  cow's  milk  + 

10  a.  m.  ;    2:12  p.  m. 

Practically  continuous  hunger  periods  until  3:15  p.  m. 

general  diet 

III  1 

10  a.  m.       2:16  p.  m. 

Ono  hunger  period  at  2:45  p.  m.  to  2:50  p.  m.    Hunger 

contractions    practically    continuous    after   3   p.    m. 

until  4:50  p.  m. 

11/10 

160  c.c.  cow's  milk  at 

2  p.  m.  ,    2:45  p.  m. 

Observations  continued   until  5:10  p.  m.     No  hunger 

preceding  feeding 

periods,  but   child   cried  or  was   restless    over   half 

of  the  time 

10/11 

160  c.c.  cow's  milk  at 

2p.m.      9:00  p.m. 

Practically  continuous  contractions  until  11  p.  m. 

preceding  feeding 

11/11 

200  c.c.  protein  milk  + 

5p.m.     10:12  p.m. 

Practically  continuous  contractions  until  11  p.  m. 

7%  dextrimaltose 

11/12 

200  c.c.  protein  milk  + 

5  p.  m.       8:41  p.  m. 

First   hunger   period    at    9:30;    practically    continuous 

7%  dextrimaltose 

from  9:45  on  until  10:44  p.  m. 

11/29 

200  c.c.  protein  milk  + 

1  p.  m.       4:02  p.  m. 

First  hunger  period  began  at  4:35  p.  m.;   practically 

7%  dextrimaltose 

continuous  from  5  p.  m.  on  until  5:42  p.  m. 

12/27 

200  c.c.  protein  milk  + 

9a.m.     12:34  p.m. 

Hunger  periods  practically  continuous  until  1:30  p.  m. 

7%  dextrimaltose 

+  cereals 

12/28 

200  c.c.  protein  milk  + 

9  a.  m.  ;  12:22  p.  m. 

Hunger    periods   began    about   12:50;    hunger    periods 

7%  dextrimaltose 

became  continuous  after  1:20  p.  m. 

+  cereals 

12/30 

200  c.c.  protein  milk  + 

5a.m.     10:13  a.m. 

Practically  continuous  hunger  periods  until  11:20  a.m. 

7%  dextrimaltose 

+  cereals 

Major,  using  the  Roentgen  ray,  finds  the  emptying  time  delayed  in 
dyspepsia,  but  accelerated  in  decomposition.  With  the  same  method 
Pisek  and  LeWald  found  the  emptying  time  to  be  shorter  in  infants 
with  chronic  disturbances  of  nutrition. 

These  last  findings,  taken  in  conjunction  with  the  already  quoted 
reports  of  Tobler,  and  of  Haudek  and  Stigler,  that  the  emptying  time 
is  shortened  by  hunger,  are  suggestive  of  the  results  here  obtained 
experimentally  ;  that  is,  the  greater  gastric  hunger  contraction  in  infants 
with  chronic  nourishment  disturbance. 

Not  only  is  the  interval  for  development  of  hunger  shorter  in  such 
infants,  but  the  contractions  become  much  more  intense.  Nov.  10, 


17 

1916,  the  2-year-old  boy  (Table  2),  whose  weight  in  spite  of  a  calori- 
cally  sufficient  intake  had  remained  stationary,  and  whose  temperature 
had  been  irregular,  developed  fever  and  diarrhea.  After  eight  hours 
of  starvation,  with  temperature  normal,  the  graphic  record  of  his  gas- 
tric activities  resembled  those  of  the  starving  pigeon  and  of  the  pre- 
mature infant  already  mentioned.  The  contractions  were  continuous 
and  required  only  twelve  seconds  for  their  completion.  Next  day  the 
child  was  put  on  protein  milk  and  thereafter  improved. 

It  is  generally  agreed  that  mixtures  with  high  fat  content  leave  the 
stomach  most  slowly,  while  those  with  low  fat  and  high  carbohydrate 

TABLE  3. — HUNGER  IN  EXUDATIVE  DIATHESIS 
Aus.,   1   weeks  old,   Dec.    19,  1916.      Feeding  interval  4  hours,  5  times  a    day. 


Food:  Breast 

Milk  +  Butter- 

Time  ol 

Beginning 

Date 

Weight,        milk  +  Flour 

Lust 

of  Tracing 

Gm. 

+  Saccharose, 

Feeding 

C.c. 

12/19/16 

4.450 

100 

1  p.  m. 

3:28  p.  m. 

Hunger  contractions  began  at  3:30  p.m. 

Hunger  contractions  continuous  from 

3:55  to  4:37  p.  in. 

12/22/16 

4,460                      100 

9  a.  m. 

11:49  a.  m.       Hunger    contractions    present    at    11:49 

a.  m.     Hunger  contractions   continu- 

ous until  12:50  p.  m. 

12/22/16 

4,460 

150 

1:15  p.  m. 

3:34  p.  m.       Hunger  contractions  began  at  5:45  p.  m. 

I/  6/17 

4,640 

125 

8  a.  m. 

10:55  a.m.       Hunger    contractions    began    at    10:55 

a.    m.     Hunger  contractions   continu- 

ous until  12:21  p.  in. 

I/  8/17 

4,640 

125 

8:40  a.  m. 

11:51  a.m.       Hunger    contractions    began    at    12    m. 

Hunger  contractions  strong  and  con- 

tinuous after  12:18.    Babe  was  restless 

1/11/17 

4,650                      125 

8:45  a.  m. 

11:11  a.  m.       Hunger    contractions    present    by    11:45 

a.   m.     Hunger  contractions   continu- 

ous until  1:35  p.  m. 

1/13/17 

4,740 

150 

8:20  a.  m. 

11:03  a.  m.       Hunger     contractions     began     at    11:45 

a.    m.     Hunger  contractions   continu- 

ous Irom  12  to  1  p.  m. 

1/15/17 

4,770         !              150 

8:45  a.  m. 

11:01  a.m.       Hunger    contractions    present    at    11:20 

a.    m.     Hunger  contractions   continu- 

out  from  11:30  a.  m.  until  12:50  p.  m. 

1/15/17 

4,770 

150 

12:50  p.  in. 

3:21  p.  rn. 

Babe   cried    a    large    part    ol    time;    no 

evidence  ol  hunger  periods  until  5  p.  m. 

leave  most  rapidly.  In  Infants  A.  and  W.  the  time  interval  for  the 
development  of  hunger  contractions  was  much  longer  when  they 
received  low  fat  and  high  carbohydrate,  and  shorter  when  they 
received  high  fat  and  low  carbohydrate.  This  would  be  paradoxical 
if  the  gastric  hunger  contractions  depended  exclusively  on  the  empty- 
ing time. 

It  is,  then,  only  in  normal  babies,  receiving  well  tolerated  food  in 
sufficient  quantity,  that  the  development  of  hunger  waits  on  the  empty- 
ing of  the  stomach. 

The  interval  necessary  for  the  development  of  hunger  depends  in 
part  on  the  form  of  nourishment  and  is  shortest  with  that  food  which 
least  satisfies  the  infant's  tissue  need  (Table  4).  The  question  as  to 
whether  the  rapid  development  of  hunger  in  qualitatively  poorly 


19 


nourished  infants  depends  on  the  administration  of  food  deficient  in 
carbohydrate  in  particular,  or  on  the  giving  of  food  poorly  tolerated 
in  general,  is  not  answered.  Records  of  the  gastric  contractions  in 
infants  suffering  from  the  chronic  nourishment  disturbance  due  to  long 
continued  carbohydrate  overfeeding  (the  "Mehlnahrschaden"  of 
Czerny)  would  help  to  settle  this  point. 

TABLE  4.— INTERVAL  FOR  DEVELOPMENT  or  HUNGER  IN  INFANTS  WITH  CHRONIC 

DISTURBANCE  OF  NUTRITION  AND   SHOWING  INFLUENCE  OF 

CHANGE  IN  FORM  OF  NOURISHMENT 


Name 
and 
Date 

Age, 
Mo. 

Diagnosis 

Weight, 
Gm. 

Food 

Interval 
Before 
Tracing 

Time  for 
Develop- 
ment of 
First 
Hunger 
Period 

Remarks 

Til 

Sta- 

Ad 

4 

tionary 
4,080 

3300 

-f  7%  dextrimaltose 
5  times  a  day 

150  c.c.  ty  milk  + 

tial  tetanus  less  than  3 
hours  after  feeding 

2/26/17 
Ad 

4 

disorder  due  to 
overfeeding  with 
milk 

3  500 

10%  saccharose 
5  times  a  day 

present  in  2  hours  and 
20  minutes 

S/  8/17 

3 

disorder  due  to 
overfeeding  with 
milk 

5  times  a  day 

hunger  contractions 
first  appear  in  314  hrs. 

4/14/17 

ment  disturbance 
with  eczema 

4,200 

8%  fp.t.  Feeding  in- 
tervals   short    and 
irregular.  After  en- 
trance to  hospital 
fed  5  times  a  day 
150  c.c.  lfa  cow's  milk 

2hr., 

2hr., 

14,  1917 

4/23/17 

4,510 

+  10%  saccharose 

7  min. 
2br., 

7  min. 
2hr., 

after  feeding;  ^  c.c.  of 
mucus  and  thick  curd 
obtained 

5/  1/17 

4,960 

+  10%  saccharose 
150  c.c.  buttermilk  + 

10  min. 
2hr., 

10  min. 
4hr., 

of     clotted     milk     and 
clear    thin    fluid    recov- 
ered   from    stomach    3 
hours    and    25    minutes 
after   feeding 
Eczema    has   disappeared 

5/  2/17 

4,960 

flour  +  saccha- 
rose 

3  min. 
2hr., 

35  min. 
3  hr., 

5/  3/17 

4,960 

flour  +  saccha- 
rose 

27  min. 
57  min. 

12  min. 
3  hr.. 

flour  +  saccha- 
rose 

20  min. 

terial  removed  from 
stomach  20  minutes 
after  beginning  of  first 
contraction  period 

Attention  has  already  been  called  to  the  heightened  electrical  reac- 
tions found  by  Zybell  in  hungry  infants.  I  also  wish  to  mention  the 
findings  of  Finklestein,  Thiemich  and  Japha  that  the  electrical  irrita- 
bility is  frequently  heightened  in  artificially  fed  infants,  and  of  Czerny 
and  Moser  that  there  is  an  increase  in  the  electrical  irritability  of 
infants  suffering  with  "Mehlnahrschaden."  It  is  possible  that  the 
heightened  electrical  irritability  in  all  depends  on  the  increased  hunger 
contractions  due  again  in  part  to  the  constant  chemical  stimulation 
reaching  the  stomach  from  the  semistarved  tissues. 


20 

Most  premature  infants  and  many  young  infants  nurse  poorly. 
The  consequent  effect  on  lactation  and  on  the  babe's  nourishment  is 
serious.  An  extensive  literature  on  this  subject  has  been  developed 
in  German,  but  there  is  surprisingly  little  in  French  and  in  English. 

In  1888  Auerbach  described  the  infantile  manner  of  sucking,  which 
depends  on  the  chewing  muscles,  and  Escherich  showed  its  teleologic 
importance.  The  reflex  paths  and  center  in  the  medulla  were  demon- 
strated in  1894  (Basch).  Cramer,  Suszwein,  Finklestein,  Rott,  Rosen- 
stern,  Barth  and  Kasahara  have  further  studied  the  question  and  report 
results  which  in  general  support  the  theory  that  the  inability  to  nurse 
well  is  to  be  attributed  primarily  to  an  imperfect  nervous  mechanism 
and  not  to  muscular  weakness. 

For  further  elucidation  of  the  question,  tracings  of  the  movements 
of  the  empty  stomach  were  taken  in  two  infants  who  were  extreme 
examples. 

The  first  baby  (Baby  M.),  weighing  2,700  gm.  at  birth  and  pre- 
senting no  anatomic  peculiarities,  took  very  little  from  the  mother's 
breast  during  the  first  three  weeks,  although  sufficient  milk  was 
expressed  therefrom  to  feed  the  baby  and  to  complement  the  feedings 
of  other  babies. 

The  second  infant  (Baby  T.),  aged  3  months,  had  weaned  himself 
from  the  breast,  had  developed  dyspepsia  and  atrophy  on  artificial 
feeding,  and  could  be  made  to  take  his  food  from  the  bottle  only  with 
great  difficulty.  He  seemed  able  to  fix  his  attention  on  anything  other 
than  the  act  of  feeding. 

In  these  infants  as  well  as  in  the  five  prematures,  and  in  one  typical 
case  of  congenital  myxedema,  hunger  contractions  of  at  least  normal 
force  and  duration  were  present.  At  the  time  they  were  studied,  none 
of  the  infants  was  able  to  nurse  successfully.  In  all,  the  sucking  reflex 
was  qualitatively  present. 

This  study  does  not  solve  the  problem  as  to  the  causation  of  feeble 
nursing,  but  does  limit  the  field  of  possibilities  by  excluding  derange- 
ments of  the  primitive  hunger  apparatus. 

Carlson  reports  Rupp's  finding  that  hunger  contractions  persist 
during  the  fever  excited  by  the  administration  of  typhoid  vaccine. 
The  boy  with  the  gastric  fistula  contracted  typhoid  fever  from  a 
carrier.  Tracings  taken  while  his  rectal  temperature  ranged  between 
104.4  F.  and  105  F.,  show  the  presence  of  hunger  contractions. 

Carlson  and  Ginsburg  found  hypertonicity  and  hypermotility  in  the 
stomachs  of  two  infants  with  pylorospasm  and  stenosis.  From  a  six 
weeks'  old  infant  (Baby  S.)  with  pyloric  stenosis,  I  obtained  records 
which  agree  with  Carlson  and  Ginsburg's  description  of  periods  of 
tetanus  lasting  several  minutes  interspersed  with  vigorous  contractions 
of  normal  duration. 


21 

Carlson  suggests  that  pylorospasm  and  stenosis  may  be  an  expres- 
sion of  gastric  hypermotility.  His  cases  were  seen  late,  as  was  the  one 
here  reported.  In  the  absence  of  tracings  taken  at  the  beginning  of  the 
disease,  it  is  likely  that  the  hypermotility  results  from  the  inanition 
following  the  obstruction  at  the  pylorus.  And  without  definite  knowl- 
edge that  the  stomach  was  washed  empty,  the  long  periods  of  tetanus 
observed  may  represent  the  so-called  visible  gastric  peristalsis. 

SUMMARY 

The  study  of  fifty-six  infants  from  birth  to  2  years  of  age  gives 
the  following  results : 

1.  Confirmation  of   previous   work,  that  hunger  contractions   are 
greater  in  the  new-born  infant,  with  description  of  these  contractions. 

2.  Determination   of   the    still   greater   hunger   contraction   in   the 
stomachs  of  prematurely  born  infants,  with  description  of  these  con- 
tractions. 

3.  There  is  no  relation  between  cyanosis  and  hunger  contractions. 

4.  Inhibition  of  the  hunger  contractions  from  the  mouth  does  not 
occur  in  young  infants. 

5.  Inhibition  of  the  hunger  contractions  from  the  mouth  in  older 
infants  is  present  only  as  the  result  of  stimuli,  which  the  babe  has 
learned  to  recognize  as  food.     It  does  not  occur  with  substances  pro- 
ducing equally  strong  sensory   impressions,  but   which   are  not  con- 
sidered by  the  infant  as  food. 

6.  Inhibition  from  the  mouth  is  psychic  in  character. 

7.  Reflex  inhibition  from  the  presence  of  food  in  the  stomach  is 
present  in  infants  of  all  ages. 

8.  This  reflex  inhibition  from  the  stomach  may  be  only  partially 
developed  in  young  infants. 

9.  Successive    automatic    sucking   movements  — •  each    sucking   act 
serving  as   the   stimulus   for  its   successor  —  are   present   during  the 
hunger  state,  when  the  reflex  threshold  is  kept  almost  constantly  low 
by  a  rapid  succession  of  hunger  contractions. 

10.  In  normally  developing  breast  fed  babes,  hunger  is  not  ordi- 
narily an  immediate  cause  of  crying. 

11.  The  average  time  required  for  the  development  of  hunger  in 
healthy   infants  gaining  in   weight  and   receiving  a   known   sufficient 
amount  of  food  is,  in  prematures,  under  one  month,  one  hour  and 
forty  minutes,  with  a  maximum  of  two  hours  and  twenty  minutes  and 
a  minimum  of  forty  minutes;  in  full  term  infants  under  two  weeks, 
two  hours  and  fifty  minutes,  with  a  maximum  of   four  hours  and  a 
minimum  of  two  hours;  in  infants  from  two  weeks  to  four  months. 


22 

three  hours  and  forty  minutes,  with  a  maximum  of  four  hours  and 
thirty-five  minutes  and  a  minimum  of  three  hours  and  twelve  minutes 
(Table  1). 

12.  The  time  required  for  the  development  of  hunger  in  any  one 
infant  is    fairly  constant  over  a  short  period   of  time  provided   the 
amount  and  kind  of  food  is  not  changed  (Tables  1,  2,  3  and  4). 

13.  The  time  required  for  the  development  of  hunger  in  infants 
with  chronic  nourishment  disturbance  is  shorter  than  in  normal  infants 
(Tables  2,  3  and  4). 

14.  The  time  required  for  the  development  of  hunger  is  shorter 
when  the  infant  receives  food  which  is  poorly  tolerated  (Table  4). 

15.  Hunger   contractions   occur  in   these   infants   long  before   the 
stomach  has  emptied.     Consequently  their  presence  is  not  in  itself  an 
indication  that  the  stomach  is  ready  for  food. 

16.  The  feeble  nursing  exhibited  by  most  prematures  and  by  many 
older   infants   is   not   due   to   derangement    of    the   primitive   hunger 
apparatus.     Hunger  contractions  are  present  and  of  normal  intensity 
in  such  infants. 

17.  Hunger  contractions  were  present  in  one  infant  with  congenital 
myxedema. 

18.  Hunger  contractions  were  present  in  a  2-year-old  boy  with 
typhoid  fever  when  the  rectal  temperature  ranged  between  104.4  F. 
and  105  F. 

19.  Confirmation  of  previous  findings  of  increased  hunger  con- 
tractions in  infants  with  pyloric  stenosis. 

I  wish  to  express  my  sincere  thanks  to  Dr.  A.  J.  Carlson  of  the  University  of 
Chicago  for  suggestions  which  aided  materially  in  carrying  out  these  studies; 
to  Dr.  E.  P.  Lyon  and  Dr.  A.  D.  Hirschf elder  for  the  loan  of  apparatus  from 
the  departments  of  physiology  and  pharmacology ;  to  Dr.  F.  H.  Scott  and  Dr. 
F.  B..  Kingsbury  for  advice  and  assistance  in  the  construction  of  apparatus ;  to 
Dr.  F.  W.  Schultz  for  the  use  of  material  from  the  Infant  Welfare  Clinic;  to 
Dr.  N.  O.  Pearce,  teaching  fellow  in  pediatrics,  and  to  head  nurses  Barber  and 
Wenck,  who  cheerfully  assisted  in  preparing  the  little  patients  for  examination. 

To  my  chief,  Dr.  J.  P.  Sedgwick,  who  first  suggested  this  problem,  and  who 
allowed  the  free  use  of  his  material  in  the  service  at  the  university  hospitals,  I 
wish  to  express  my  grateful  appreciation  for  constant  stimulating  interest  and 
helpful  suggestions. 

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24 

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61.  Tobler   and    Bogen,    H. :    Ueber    die    Dauer    der    Magenwerdauung   der 
Milch    und    ihre    Beeinflussung   durch    verschiedene    Faktoren.      Monatschr.    f. 
Kinderh.,  1908-1909,  7,  12. 

62.  Zybell :     Beitrage    zur    Behandlung    der    Spasmophilie.      Miinchen.    med. 
Wchnschr.,  1911,  58,  2357. 


HUNGER   AND   APPETITE   SECRETION    OF   GASTRIC 
JUICE    IN    INFANTS'    STOMACHS* 

ROOD    TAYLOR,    M.D.,    Sc.D. 
Mayo  Clinic 

ROCHESTER,    MINN. 

There  is  apparently  a  gastric  element  in  appetite.  The  contractions 
of  the  stomach  institute  hunger.  Its  profuse  and  rich  secretion  causes 
an  entirely  different  sensation  —  not  painful,  but  pleasant.  Carlson 
concludes  that  the  appetite  or  psychic  gastric  juice  described  by  Paw- 
low1  stimulates  sensory  nerve  endings  in  the  gastric  mucosa.  The 
resulting  sensation  resembles  that  which  follows  the  first  few  mouth- 
fuls  of  good  food  at  a  meal  to  which  one  has  come  hungry,  and  directs 
the  flow  of  consciousness  toward  the  matter  of  taking  food. 

Pediatric  literature  contains  many  references  to  this  secretion. 
Bauer  and  Deutsch  found  no  gastric  juice  in  the  baby's  stomach  after 
it  had  reached  eagerly  for  its  bottle.  Pfaundler  noted  that  in  babes 
who  nursed  actively  the  stomach  emptied  sooner,  and  the  degree  of 
acidity  attained  was  higher  than  in  babes  who  were  fed  passively  or 
through  the  tube.  Cohnheim  and  Soetbeer,  working  with  gastrotomized 
new-born  pups,  obtained  juice  containing  hydrochloric  acid  even  when 
the  pups  nursed  on  nonlactating  breasts.  A.  H.  Meyer  found  a  great 
variation  in  gastric  acidities  in  the  same  child  and  conjectured  that  the 
variations  might  depend  on  the  presence  or  absence  of  Pawlow's  appe- 
tite juice.  Schmidt  writes  that  the  infant  on  the  breast  works  and 
stimulates  the  secretion  of  gastric  juice.  Meisl  advocates  the  use  of  a 
pacifier  before  meals  to  cause  the  flow  of  appetite  juice.  Bogen,  whose 
material  included  a  31/2-year-old  boy  with  a  stenosed  esophagus  and 
gastric  fistula,  concludes  that  psychic  secretion  of  gastric  juice  does 
occur.  Nothmann,  in  1909,  formally  investigated  the  question  of  the 
secretion  of  appetite  juice  by  the  infant's  stomach,  and  concluded  that 
it  took  place  even  immediately  after  birth.  Rosenstern  advised  the  use 
of  pepsin  and  hydrochloric  acid  to  stimulate  the  appetite  of  infants 
who  nurse  poorly.  Bonniger  could  find  in  pups  no  relation  between 
the  kind  of  food  and  the  secretion  of  gastric  juice. 

With  the  exceptions  of  the  work  done  on  pups,  and  Bogen's  work 
on  a  S^-year-old  boy,  the  foregoing  is  all  brought  into  question  because 
it  relies  on  the  use  of  the  ordinary  catheter  or  stiff  stomach  tube,  which 


*  From  the  Department  of  Pediatrics,  University  of  Minnesota. 

1.  References  to  the  literature  will  be  found  at  the  end  of  the  article. 


27 

does  not  permit  accurate  quantitative  studies.  A  still  more  serious 
criticism,  and  one  which  leaves  the  whole  subject  open,  is  that  in  none 
of  the  quoted  work  is  the  possibility  of  a  continuous  secretion  of  gastric 
juice  sufficiently  taken  into  account. 

In  1888  Leo  found  free  hydrochloric  acid  in  the  stomachs  of  unfed 
new-born  babes,  and  noted  that  in  older  infants  the  stomach  was  rarely 
entirely  empty,  so  that  he  could  usually  recover  a  few  drops  of  thick, 
yellowish  acid  fluid.  He  washed  out  the  stomach  and  again  inserted 
the  tube  and  then  obtained  only  wash  water  from  the  preceding  wash- 
ings. Consequently  Leo  concluded  that  the  acid  juice  obtained  by  him 
from  the  "empty"  stomach  was  the  gastric  juice  remaining  from  the 
last  meal,  concentrated  by  the  absorption  of  water.  Wohlmann 
reported  that  the  secretion  of  the  infant's  empty  stomach  is  viscid, 
colorless,  glassy,  and  without  free  hydrochloric  acid.  Wohlmann  took 
his  specimens  from  one  to  two  hours  after  feeding.  The  teachings  of 
Pawlow  that  gastric  secretion  depends  on  appetite  or  on  food  or  other 
stimuli  in  the  stomach  impressed  the  medical  mind  so  deeply  that  until 
the  present  decade  all  gastric  secretion  was  interpreted  in  the  light  of 
his  investigations.  A.  H.  Meyer  concluded  that  the  passage  of  the 
stomach  tube  does  not  excite  the  secretion  of  acid  gastric  juice.  Paw- 
low's  published  work  supports  the  same  conclusion.  Engel  reports  a 
4-week-old  babe  with  pyloric  stenosis  and  a  jejunal  fistula.  From  this 
infant,  who  was  fed  through  the  fistula,  Engel  obtained  by  way  of  the 
esophagus  from  60  to  200  c.c.  of  gastric  juice  daily.  The  total  acidity 
of  this  juice  ranged  from  60  to  70  and  was  nearly  entirely  made  up  of 
free  hydrochloric  acid.  Engel  was  unable  to  explain  his  findings  except 
on  the  basis  of  a  pathologic  hypersecretion,  which  he  thought  might 
have  caused  the  pyloric  stenosis.  Alfred  F.  Hess,  in  1913,  showed  that 
the  stomach  of  the  unfed  new-born  babe  secretes  a  highly  acid  juice, 
and  he  concluded  further  that  saliva  does  not  act  as  a  stimulus  to  the 
production  of  such  juice.  He  was  unable  to  determine  a  relationship 
between  the  amount  of  sucking  and  the  amount  of  juice  secreted. 
Sedgwick  recovered  acid  stomach  and  duodenal  contents  three  and  four 
hours  after  nursing.  In  1905  Boldyreff  reported  continuous  secretion 
of  the  gastric  glands  in  starving  dogs.  Ten  years  later  Fowler,  Rehfuss 
and  Hawk  concluded  that,  in  man,  the  gastric  glands  are  never  idle, 
while  Carlson  demonstrated  the  continuous  secretion  of  gastric  juice 
in  the  empty  stomach  of  normal  adults.  Referring  to  its  secretion 
during  the  hunger  state,  Carlson  calls  it  hunger  juice. 

It  is  evident  that  the  determination  of  the  secretion  of  an  appetite 
juice  in  the  infant's  stomach  must  be  made  in  conjunction  with  the 
determination  of  its  continuous  secretion. 

The  flexible  tube  with  the  slotted  weight  at  the  tip  described  by 
Rehfuss,  combined  with  any  simple  syringe  for  gentle  aspiration,  makes 


28 

an  excellent  instrument  for  the  study  of  the  physiology  of  the  stomach 
of  the  infant.  A  smaller  tip  can  be  made  for  those  infants  who  cannot 
swallow  the  ordinary  tip.  With  this  apparatus  I  have  repeatedly 
recovered  from  the  infant's  stomach  the  entire  30  to  50  c.c.  of  water 
introduced  into  it  and  never  have  lost  more  than  2  c.c.  in  the  washing. 
Furthermore,  large,  thick,  gelatinous  clumps  of  mucus  and  curd  are 
removed  without  difficulty. 

In  order  to  avoid,  as  far  as  possible,  contaminating  the  gastric  juice 
with  saliva,  and  to  permit  the  carrying  out  of  sham  feeding,  I  converted 
a  No.  21  F.  soft  rubber  catheter  into  an  outer  casing  for  the  Rehfuss 
tube.  When  in  place  this  outer  casing  terminates  internally  in  the 
esophagus,  and  externally  with  a  suction  apparatus.  The  whole  is 
explained  in  the  accompanying  illustration,  which  is  one-half  actual  size. 


Bulb  |or  collection 
of  saliva, milk  etc 


To   Syringe   |or 

collection  o 
gastric    iuice 


Lnd  o|  outer  casing 


tip 
n  stomach 


Author's   apparatus    for   removing  gastric   contents    from   infants;   one-half 
actual  size. 

The  experimental  procedure  was  as  follows:  If  the  babe  fasted  all- 
night,  he  was  given  water  at  5  a.  m.  in  quantity  equivalent  to  his  usual 
feeding.  When  the  stomach  was  examined  a  few  hours  later,  milk 
remains  were  never  found.  If  the  period  without  food  were  shorter, 
his  stomach  was  thoroughly  washed  out  and  observations  begun  an 
hour  later. 

If  no  aspiration  is  applied  to  the  stomach  tube  during  the  half  hour, 
the  amount  obtained  is  usually  less  than  1  c.c.  The  usual  procedure 
was  to  insert  the  tube,  exert  suction  to  empty  the  stomach  of  any  con- 
tent, then  allow  the  tube  to  remain  one-half  hour  without  suction,  and 


29 

collect  the  specimen,  if  any.  Repeat  the  procedure,  exerting  gentle 
suction  every  two  and  one-half  minutes  and  collect  the  specimen. 
Exert  suction  in  the  same  way  during  a  third  half  hour  while  the  sham 
feeding  progresses.  The  final  two  specimens  only  are  listed  in  the 
accompanying  table. 

As  a  rule,  no  secretion  was  obtained  for  five  minutes  after  the  inser- 
tion of  the  tube.  On  one  occasion  gastric  juice  containing  free  hydro- 
chloric acid  was  obtained  within  two  minutes  of  the  time  at  which 
introduction  of  the  tube  began  (Baby  A.).  This  is  less  than  the  latent 
time  usually  required  by  the  gastric  glands  (Carlson,  Pawlow)  and  is 
further  evidence  that  the  secretion  here  obtained  was  not  produced 
artificially  by  the  apparatus. 

To  stimulate  an  appetite  secretion,  the  babe  was  given  a  pacifier 
threaded  over  the  tube,  or,  the  food  to  which  he  was  accustomed  was 
administered  by  a  medicine  dropper,  or,  with  the  artificially  fed  babes, 
from  their  usual  nursing  bottle.  The  infant  always  sucked  vigorously 
during  this  procedure.  If  the  babe  sucked  before  sham  feeding  began, 
it  has  been  noted  in  the  table.  As  a  rule,  the  babes  slept  or  were  quiet 
and  did  not  suck,  except  after  the  beginning  of  the  sham  feeding.  The 
presence  of  the  tube  seemed  to  discommode  these  babes  very  little. 
There  certainly  was  no  psychic  excitement  to  depress  the  action  of  the 
gastric  glands  while  the  babes  were  smacking  and  sucking  over  their 
food. 

In  three  cases  only,  as  noted  in  the  table,  did  food  reach  the  stom- 
ach. Strictly  speaking,  neither  these  instances  nor  the  specimens  which 
contained  blood  should  be  considered  as  offering  evidence  on  either  the 
subject  of  "hunger"  or  "appetite"  gastric  juice.  The  only  demon- 
strable effect  of  the  blood,  which  was  never  present  in  more  than  a 
trace,  was  to  lower  the  acid  titration  values.  On  the  three  occasions 
on  which  milk  reached  the  stomach,  larger  amounts  of  secretion  was 
obtained. 

The  titrations  were  done  against  tenth-normal  sodium  hydroxid, 
using  di-methyl-amino-azobenzol  and  phenolphthalein  as  indicators. 
The  hydrogen-ion  concentrations  were  done  by  the  gas  chain  methoG. 
I  wish  to  thank  Dr.  J.  F.  McClendon  for  his  courtesy  in  allowing  the 
use  of  his  apparatus. 

The  "appetite"  gastric  juice  is  characterized  by  its  relatively  pro- 
fuse secretion  and  high  acidity.  Neither  characteristic  was  present  in 
the  juice  obtained  after  sham  feeding  in  these  infants.  On  the  con- 
trary, the  juice  obtained  differed  little  in  character  and  quantity  from 
that  obtained  before  sham  feeding  was  begun. 

It  will  be  seen  that  the  empty  stomach  of  the  infant  continuously 
secretes  a  juice  which  at  times  is  as  acid  as  that  of  the  adult,  and  that 
the  infant's  stomach  does  not  secrete  an  "appetite"  or  psychic  juice. 


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31 

This  accords  with  the  absence  of  psychic  inhibition  of  the  hunger  con- 
tractions. 

As  indicated  by  the  digestion  of  egg  white  in  Mett's  tube,  the 
infant's  hunger  juice  contains  pepsin. 

Reiche  has  demonstrated  the  absence  of  a  duodenal  reflux  into  the 
infant's  stomach.  The  present  findings  support  his  conclusion.  What, 
then,  becomes  of  this  continuous  secretion  under  circumstances  such  as 
enforced  therapeutic  starvation  from  twenty-four  to  forty-eight  hours? 
Pfaundler  has  conjectured  that  at  the  close  of  digestion  the  alkaline 
secretion  of  the  pyloric  glands  gradually  neutralizes  the  acid  content 
of  the  stomach.  I  cannot  support  this  view.  The  finding  of  a  greater 
quantity  of  juice  when  a  more  continuous  suction  is  maintained,  the 
frequent  absence  of  juice  when  the  tube  is  first  inserted,  and  Sedg- 
wick's  finding  that  the  young  infant's  duodenal  contents  are  acid,  favor 
the  conclusion  that  at  least  a  portion  of  this  juice  makes  its  way  into 
the  intestine. 

It  seems  probable,  therefore,  that  the  secretion  of  the  alkaline  pan- 
creatic and  intestinal  juices,  which  in  the  adult  regurgitate  into  the 
stomach,  as  demonstrated  by  Boldyreff,  and  lower  the  acidity  of  the 
juice  in  the  stomach  (Carlson,  Rehfuss  and  Hawk  and  Boldyreff),  is, 
in  the  infant,  relatively  deficient. 

The  hunger  juice  is  delivered  through  the  tube  intermittently.  The 
most  profuse  secretion  is,  as  a  rule,  associated  with  the  higher  acidities ; 
this  is  also  true  in  the  adult  (Carlson).  The  largest  amounts  were 
obtained  from  one  of  the  unfed  new-born  babes  and  from  the  older 
infants.  It  is  readily  seen  that  the  stomach  of  the  starving  infant  can 
secrete  from  SO  to  200  c.c.,  or  more,  of  highly  acid  juice  daily.  This 
equals  the  amount  Engel  obtained  from  his  case  of  pyloric  stenosis, 
which  has  served  as  the  clinical  basis  for  the  theory  that  hyperacidity 
or  hypersecretion  of  the  gastric  juice  is  an  etiologic  factor  in  that  dis- 
ease. 

Furthermore,  this  demonstration  of  the  capacity  of  the  infant's 
stomach  to  secrete  a  highly  acid  juice,  makes  it  probable  that  the  low 
acid  values  found  during  gastric  digestion  of  milk  are  in  part  due  to  its 
binding  power  for  acid  (Aron),  and  in  part  due  to  the  relatively  slight 
stimulation  which  it  exerts  on  the  gastric  glands  (Pawlow,  Moore  and 
Allanson).  Huenekens  found  a  hydrogen  ion  concentration  of  174  X 
10'r'  in  a  9i/2-months-old  infant  after  a  meal  of  soup  and  vegetables. 
Most  of  his  results  were  lower,  however.  No  such  studies  have  been 
made  in  younger  infants. 

Experience  in  the  clinic  of  the  University  of  Minnesota  and  in 
other  clinics  (Rott)  has  proved  the  advantage  which  is  gained  in  feed- 
ing the  premature  infant  by  tube.  Theoretical  objections  to  the  use  of 


32 

the  tube  have  been  based  principally  on  the  assumed  existence  of  an 
appetite  gastric  juice  (Pfaundler). 

The  amount  of  saliva  collected  during  the  experiments  on  gastric 
secretion  was  measured  in  six  cases. 

W. —  7  days No  sham  feeding 7  c.c.  in  40  minutes 

H. — 17  days Sham  feeding 14  c.c.  in  2     hours 

P. —  1  mo Sham  feeding 25  c.c.  in  1.5  hours 

Ne. — 11  days Sham  feeding 15  c.c.  in  1.5  hours 

P. —  9  days Sham  feeding 8  c.c.  in  1.5  hours 

S. — 12  days Sham  feeding 10  c.c.  in  1.5  hours 

The  saliva  collected  was  the  thick  viscid  product  of  the  submaxil- 
lary  glands,  which  Schilling  has  noted  as  being  preponderant  during 
early  infancy. 

Allaria  points  out  the  chemical  and  mechanical  advantages  of 
having  the  milk  well  mixed  with  saliva,  and  estimates  that  the  infant 
secretes  an  amount  equal  to  from  10  to  20  per  cent,  of  the  ingested 
food.  The  tube-fed  infant  may  do  without  this  secretion  in  part  or 
altogether,  but  there  is  no  evidence  that  his  gastric  secretion  is  less  than 
that  of  the  actively  nursing  babe. 

What  light  does  this  study  throw  on  deprivation  of  food  as  a  thera- 
peutic agent?  In  infancy  such  a  measure  finds  its  chief  field  in  acute 
alimentary  disorders  and  summer  diarrheas.  The  significant  fact  is 
that  in  hunger  the  infant's  stomach  secretes  continuously,  but  with 
intermittent  intensity,  a  highly  acid  juice,  which  at  least  in  part  flows 
into  the  small  intestine  where  it  may  play  a  disinfecting  or  detoxicating 
role. 

SUMMARY 

1.  Description   of   an   apparatus   by  which   sham    feeding  can   be 
carried  out  and  gastric  juice  collected  under  conditions  which  give 
positive  evidence  of  the  amount  secreted. 

2.  There  is  no  appetite  or  psychic  secretion  of  gastric  juice  in  the 
young  infant.     This  disproves  the  present  view,  which  is  based  on 
insufficient  experimental  evidence. 

3.  The  empty  stomach  of  the  hungry  babe  secretes  a  gastric  juice 
which  often  is  as  acid  as  that  found  in  the  adult's  stomach. 

4.  The  more  profuse  this  secretion,  the  higher  is  its  acidity.     It 
contains  pepsin. 

5.  This  secretion  is  not  neutralized  in  the  stomach,  but  flows  out 
into  the  small  intestine.     Regurgitation  through  the  infant's  pylorus 
does  not  occur. 

6.  The  theoretical  objections  to  tube  feeding  in  prematures  because 
of  the  lack  of  stimulation  of  an  appetite  gastric  juice  are  not  valid. 
However,  a  disadvantage  may  lie  in  this :  that  such  feeding  precludes 
the  usual  admixture  of  the  milk  with  saliva. 


.53 

Therapeutic  starvation  in  acute  alimentary  disorders  and  in  summer 
diarrheas  may  owe  its  success  in  part  to  the  heightened  tonus  of  the 
alimentary  tract,  and  in  part  to  the  pouring  out  of  highly  acid  detoxi- 
cating  and  disinfecting  gastric  juice  into  the  small  intestine. 

I  wish  to  acknowledge  my  indebtedness  to  Dr.  J.  P.  Sedgwick  for  the  use 
of  material  from  his  service  in  the  University  of  Minnesota  Hospital. 

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34 

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